I.

Introduction

A. Current trends of the condition Intestinal obstruction Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. Causes Obstruction of the bowel may due to:

A mechanical cause, which simply means something is in the way Ileus, a condition in which the bowel doesn't work correctly but there is no structural problem

Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal obstruction in infants and children. Causes of paralytic ileus may include:

Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels) Complications of intra-abdominal surgery Decreased blood supply to the abdominal area (mesenteric artery ischemia) Injury to the abdominal blood supply Intra-abdominal infection Kidney or lung disease Use of certain medications, especially narcotics

In older children, paralytic ileus may be due to bacterial, viral, or food poisoning (gastroenteritis), which is sometimes associated with secondary peritonitis and appendicitis. Mechanical causes of intestinal obstruction may include:

Abnormal tissue growth Adhesions or scar tissue that form after surgery Foreign bodies (ingested materials that obstruct the intestines) Gallstones Hernias Impacted feces (stool) Intussusceptions Tumors blocking the intestines Volvulus (twisted intestine)

Symptoms

Abdominal distention Abdominal fullness, gas Abdominal pain and cramping Breath odor Constipation Diarrhea Vomiting

Site of Obstruction

Cause

Relative Incidences (%)

Small intestine [85%]

Adhesions

60

Hernia Tumors miscellaneous Large Intestine [15%] CA colon

15 15 10 65

Diverticulitis Volvolus miscellaneous

20 5 10

Life cycle of Ascaris lumbricoides. Epidemiology Frequency United States In the United States, approximately 4 million people are believed to be infected. Highrisk groups include international travelers, recent immigrants (especially from Latin America and Asia), refugees, and international adoptees. Ascariasis is indigenous to the rural southeast, where cross-infection by pigs with the nematodeAscaris suum is thought to occur. (Children aged 2-10 years are thought to be more heavily infected in this and all other regions.) International Worldwide, 1.4 billion people are infected with A lumbricoides, with prevalence among developing countries as low as 4% in Mafia Island, Zanzibar, to as high as 90% in some areas of Indonesia. Local practices (eg, termite moundeating in Kenya[3] ) may predispose to ascariasis in some populations. Other risk factors like dog/cat ownership, presence of pets within the house, and a previous history of geophagia have been noted. In some regions, Ascaris infection is thought to contribute significantly to the burden of abdominal surgical emergencies.

Mortality/Morbidity The rate of complications secondary to ascariasis ranges from 11-67%, with intestinal and biliary tract obstruction representing the most common serious sequelae. Although infection with A lumbricoides is rarely fatal, it is responsible for an estimated 8,000100,000 deaths annually, mainly in children, usually from bowel obstruction or perforation in cases of high parasite burden. Due to similarities in the means of infection, many individuals infected with Ascaris are also co-infected with other intestinal parasites. Race No racial predilection is known. A genetic predisposition has been described in a study of families from Nepal. Sex Male children are thought to be infected more frequently, owing to a greater propensity to eat soil. Age Children, because of their habits (eg, directly or indirectly consuming soil), are more commonly and more heavily infected than adults. Neonates may be infected by transplacental infection. Frequently, families may be infected and reinfected in group fashion due to shared food and water sources as well as hygiene practices. History Most patients are asymptomatic. When symptoms occur, they are divided into 2 categories: early (larval migration) and late (mechanical effects).

In the early phase (4-16 d after egg ingestion), respiratory symptoms result from the migration of larvae through the lungs. Classically, these symptoms occur in the setting of eosinophilic pneumonia (Lffler syndrome). o Fever o Nonproductive cough o Dyspnea o Wheezing In the late phase (6-8 wk after egg ingestion), gastrointestinal symptoms may occur and are more typically related to the mechanical effects of high parasite loads. o Passage of worms (from mouth, nares, anus) o Diffuse or epigastric abdominal pain o Nausea, vomiting o Pharyngeal globus, "tingling throat" o Frequent throat clearing, dry cough o Complications - Biliary and intestinal obstruction, appendicitis, pancreatitis

Physical

General Fever Jaundice (in biliary obstruction) Cachexia (due to malnutrition) Pallor (anemia) Urticaria (early infection) Pulmonary Wheezing Rales Diminished breath sounds Abdominal Abdominal tenderness, which may be diffuse (in obstructive infections), or localized to the right lower (appendicitis) or right upper quadrant (hepatobiliary infections) Peritoneal signs in cases of bowel perforation Obstructive symptoms (nausea/vomiting/constipation/distention) Migrating larvae may transmit other organisms, causing bacterial pneumonia orcholangitis. Rare cases of airway obstruction have also been reported. Other much less common presentations include lacrimal drainage obstruction, small bowel intussusception, acute interstitial nephritis, and encephalopathy. Causes

Symptoms are typically associated with early larval migration, heavy intestinal burdens of adult worms, or aberrant worm migration. Worm migration may be stimulated by anesthetic agents, fever, or subtherapeutic anthelmintic treatment, or by use of certain anthelmintics (eg, pyrantel pamoate).

B. Reason for choosing the case Having a disease can greatly affect the functioning of the body but the reason behind why such case happen can create confusion. To motivate and provide continuity of learning in the nursing profession, the student-nurses had chosen this case presentation to enlighten them as to have a single condition which can lead to serious disease and can create complications that prevents the individual from functioning well. The student-nurses chose this case for them to disseminate the appropriate teachings to the significant others to prevent exacerbation, decrease the incidence ad for the student nurses to be effective nurses in preventing the illness. The information that were gathered may also serve as a guide in promoting health to the patients.. With this in mind, the student nurses intend to find out all the necessary data to draw a conclusion

on what caused this to happen and to serve as a way to inform the public regarding the disease condition through the presentation of this particular case through a nursing perspective. The student-nurses would like to be of great help to the patient and her family in terms of shedding light with regards to what the patient is suffering from and why. The student-nurses understand that the information that would be shared to the patient and her family would bring clarity to them. Enhancing the student nurses understanding and competence for they to be able to impart the best possible care to their patient is another justification to be considered. The student nurses believed that learning should not only be confined in the four corners of our classrooms, but it should also be derived from the people we bestow our utmost concerns. This will widen their knowledge because new uncommon diseases and how to deal with it. To identify what is the best intervention for a patient who suffers such disease.

II. Nursing Assessment A. Personal History 1. Demographic Data To secure confidentiality with our patient, he will be referred as Jelly ace is a five year old boy of Kapampangan descent and was born on June 27,2007. He lives at Abacan Malabaas Balibago. Theyre only two in the family and he is the oldest. He was admitted at the hospital on June 21,2012. 2. Socio-economic and Cultural factors b.1 Income and expenses (occupation) He grew up with his grandmother who is 54 years old. Theyre eleven in the house. Her grandmother stays in the house while his grandfather was working mamisaling kalakal. His two sons, works too as construction workers. Some of her children were separated with her including the parents of angel. b.2 Educational attainment Jelly ace is studying at Tinio Elementary School. He is currently in preparatory level. b.3 Religion Affiliation According to his grandmother, their religion was Catholic. b.4 Cultural factors affecting health of the family Whenever the family members are sick, they sometimes resort to herbolarios for fever, cough and stomach pains where they are given different herbal

plants or helot . T h e y p r e p a r e t h e l e a v e s b y b o i l i n g t h e m i n o n e o r t w o g l a s s e s o f w a t e r f o r f i f t e e n minutes or until one-half of the liquid is left, then they will be drinking it. But most of the time, they purchase over-the-counter (OTC) drugs such as paracetamol for fever, Neozep for colds and carbocisteine for cough. And there are also some instances that these herbal plants and OTC drugs dont make them feel better, so when these things are not working to them, theyll go to the nearest public hospital . B. Family Health-Illness History Jelly Aces grandparents on maternal side are still alive but they are both hypertensive. The siblings of Jelly Aces mother, including her, are living healthy. On the other hand, on the paternal side, Jelly Aces grandparents are both alive. His grandfather is also hypertensive. And Jelly Aces father and his siblings do not have any disease present. Lastly, our client is currently diagnosed with intestinal obstruction secondary to parasitism. C. History of Past Illness During the previous years, Jelly Ace has not experienced any disease or illness. Coughs and colds were the common illness he experienced. Sometimes, he experience stomach pain. To relieve the pain, he was given different herbal plants or they buy over-the-counter drugs. For the herbal plants, they prepare the leaves of the plant then boil it with one to two glasses of water for fifteen minutes or until one half of the liquid is left. Then, he will drink it. He also experienced fever once in a while in which he takes over-the-counter drugs. D. History of Present Illness Prior to admission, the patient had experienced abdominal pain associated with episodes of LBM. Jelly Ace first went to the nearest center in their barangay and advised the grandparents to admit him at the hospital. His chief complaint was abdominal pain and LBM. E. PHYSICAL EXAMINATION

Physical Assessment Jellyace was seen lying on bed, looks weak, with an IVF of D5IMB 500 cc x 44gtts/min @ 450 level infusing well on the left hand. He was wearing a sando and a short . He looks weak. His fingernails were clean.

Vital signs:

PR:

94 bpm

T: 36.2 C

RR: 24

SKIN: Upon inspection, there was no swelling, lesions and nodules. Skin color was even with the other parts of the body. Palpation revealed no signs of masses, nodules or lesions. Skin felt warm and dry. Upon assessment of skin turgor, the skin sprung back to its previous state for less than a second. There was no more edema present in upper and lower extremities but there were some scars present in lower extremities.

HAIR: Hair appeared to black and short. It was well distributed throughout the scalp. Jelly ace hair was wet and uncombed. There was no infection and no flaking, sores, lice, nits, and ringworms were present.

NAILS: Ambers nails were cut clean and intact the angle of the nail plates curvature was approximately 160 and convex in shape which was negative of any clubbing and produced a diamond shape when asked to perform Shamroths test. The nail beds were highly vascular as evidenced by having pinkish nails no factors of cyanosis or pallor were noted. Capillary refill was less than 3 seconds. Nails were smooth no terrys nails or beaus lines were present as well as discoloration of any sort. Tissues surrounding the nails were intact and absent of infections and sores.

SKULL AND FACE The skull was normocephalic. No nodules, masses, depressions were palpated in the sides of the head. Related muscles of the face were functioning properly and symmetry of facial movements was noted as Jelly ace was asked to smile, blow, frown, and pout. There was no cracking or locking of the temporo-mandibular joint when he was asked to open the mouth. Eyebrows were aligned and had equal movement as well as the eyelashes which were well and equally distributed, curled slightly outward. Eyes were symmetrical and no presence of edema. Pupils were responsive to light and accommodation. The irises were black which the normal color was generally. There was no discoloration of sclera and remained to be transparent. The palpebral conjunctiva appeared to be shiny, smooth, and red. The cornea also appeared to be transparent, shiny and smooth; the details of the irises were also visible. Amber blinked when

the cornea was touched. Both eyes move in unison, with parallel alignment when instructed to follow the movement of the penlight. No unstable movement and jerking of eyes were noted. Lacrimal gland appeared to be intact and absent of any edema or infection. Lacrimal gland and nasolacrimal duct were absent of any tenderness or tearing.

EARS AND HEARING Ears appeared to have the same color with the rest of the facial skin and were aligned with the outer cantus of the eyes. No lesions or flakes and scales were noted. No inflammation and tenderness was noted upon palpation. Pinna recoils after it is folded. The distal thirds of the ear canal contained hair follicles there were no discharges. There was a dry cerumen on both ears. Jelly ace had no difficulty hearing normal voices and responded immediately upon hearing the tick of the watch in both ears.

NOSE AND SINUS The nose appeared to be straight and aligned; color was similar to facial skin. No lesions discharges or flaring. No tenderness, masses, or displacement of cartilages or bones were palpated. Air moved freely as the client breathed through the nares. The mucosa of the nose was pink, no lesions. Nasal septum was intact and in midline. Facial sinuses were not tender upon palpation.

MOUTH AND OROPHARYNX Outer lips were uniform pink color, soft, moist, smooth texture. There was symmetry of contour. Inner lips appeared to be pink as well, moist, smooth, soft, glistening, and elastic texture. Jelly ace had teeth (10 up, 10 down), and presence of visible dental caries was noted. He had pink and moist gums. There were no retractions of gums. The buccal mucosa had no lesions or signs of infections. It was smooth, pink, and intact. The tongue was in the center of the mouth and pink in color. It moved freely and frenulum was attached to the floor of the mouth. The soft palate was light pink and smooth. The hard palate appeared to be lighter pink and had a more irregular texture. The uvula was positioned in midline of soft palate. The oropharynx appeared to have a smooth posterior wall. The tonsils were absent of any signs of infections and appeared to be pink and smooth as well.

NECK

Neck had no edema, lesions or masses and when inspected and palpated. Jelly ace had no discomfort when moved the chin to chest and when instructed to turn the head from left to right against the applied force of the student nurse. Supraclavicular lymph nodes were not palpable. Trachea was midline of the neck; thyroid gland was neither visible upon inspection nor palpable.

THORAX AND LUNGS Anteroposterior to transverse diameter of the thorax was in 1:1. Jelly ace had no barrel chest or pigeon chest. Spine curved vertically. Spinal column is straight, right and left shoulders and hips are at same height. Upon palpation, the thorax had uniform temperature. Chest wall was intact, no tenderness; no masses. Full and symmetric chest expansion when he took a deep breath. No adventitious breath sounds were heard. Breathing patterns were quiet, rhythmic, and effortless respirations. Costal angle was at 90. Percussion notes resonated except at the scapula. Lowest point of resonance was at the diaphragm. Percussion of the ribs elicited flatness.

ABDOMEN Jelly ace abdomen was round and symmetric contour. No tenderness upon light palpation. Bowel sounds were active in all four quadrants; aortic pulsations were not visibly present. There were no friction rubs as well. No signs of enlargement of liver or spleen were present.

Cranial Nerve

Type and Function

Assessment Procedure

Expected Result

Actual Result

I.

Olfactory

Sensory Sense of smell

Ask client to close eyes and identify differed aromas

Client is expected to identify the different odors presented like alcohol and hydrogen

Jelly ace was able to identify the aroma asked without difficulty

peroxide, perfume. II. Optic Sensory Sense of vision Ask client to read fine prints at a distance of 14 inches Check visual fields by confrontation Client will be able to read fine prints (ABCD) Able to see objects in the periphery when looking straight ahead III. Oculomotor Motor Extraocular eye movement of sphincter of pupil movement of ciliary muscles of lens IV. Trochlear Motor EOM; specificall y moves eyeball downward and laterally V. Trigeminal Sensory (opthalmic Test light sensation by Client is expected to Jelly ace was able to identify Assess superior oblique muscle by downward lateral movement of each eye Client will be able to move eyes downward and laterally Jelly ace was able to move eyes downward and laterally Assess the six oculomotor movements of the eyes and pupil reaction Client is expected to move eyes from left to right, upward laterally and downward laterally Jelly ace was able to see without difficulty. He was also able to see objects within the peripheral while looking straight ahead Jelly ace was able to follow the movement of the penlight without head movement (+PERRLA)

branch) Sensation of cornea, skin of face and nasal mucosa Sensory (maxillary branch) Sense of the face and anterior oral cavity and anterior oral cavity Motor and sensory (mandibul ar branch) Jaw movement - chewing and masticatio n VI. Abducens Motor EOM; Lateral

having client close eyes and wiping a wisp of cotton over clients forehead, cheek and chin To test deep sensation, use alternating blunt and sharp ends of safety pin over the same area Assess the muscles of mastication while chewing food

identify the sensation felt and the location where the cotton or safety pin was placed

the sensation felt and the location where the cotton or safety pin touched. Client was also able to chew without difficulty

Assess lateral rectus muscle by the movement of

Client will be able to move eyes laterally

Jelly ace was able to follow the movement

movement of the eye VII. Facial Sensory Sense of taste on the anterior two thirds of the tongue Motor Movement of the muscles of the face VIII. Vestibuloco chlear Sensory (vestibular branch) Equilibriu m Sensory (cochlear branch) Sense of hearing IX. Glossophary ngeal Sensory Sense of taste on the posterior

each eye Ask client to do different facial expressions and identify various taste on the tip and sides of the tongue Client is expected to raise eyebrows, frown, smile, puff out cheeks, close eyes tightly and be able to identify various taste on the tip and sides of tongue like sweet candy and salt Allow the client to listen to the ticking of a watch on each ear while she has both eyes closed. Instruct client to walk in a straight line Assess swallowing, gag reflex and posterior tongue The client is expected to elicit gag reflex and identify bitter taste Client must be able to identify and hear the ticking sound of the wristwatch on each ear

of the penlight

Jelly ace was able to show, frown and raise eyebrows without exerting effort. He was able to identify tastes placed on the tip and sides of his tongue.

Jelly ace was able to hear and identify the ticking sound of the wristwatch on each ear and also maintain balance

Jelly ace was able to identify different flavours placed on the posterior

one third of the tongue Motor Pharynge al movement and swallowin g X. Vagus Motor and sensory Sensation of pharynx and larynx The student nurse asked the client to state name and determines hoarseness of voice XI. Accessory Motor Movement of shoulders muscle Assess shrugging of shoulders and movement of head from side to side against resistance The client must be able to shrug shoulders and move head from side to side against applied resistance XII. Hypoglossal Motor Movement of the tongue or strength of the tongue Ask client to protrude tongue and move it from side to side The client is expected to protrude tongue and move it from side to side Client must be able to state his/her name without hoarseness of voice

portion of the tongue and he was able to move his tongue; side to side and up and down

Jelly ace was able to verbally state his name without hoarseness of voice

Jelly ace was able to shrug his shoulder against applied resistance

Jelly ace was able to protrude his tongue and move it from side to side and in and out

III. Anatomy of the Digestive System The digestive system, sometimes called the gastrointestinal tract, alimentary tract, or gut, consists of a long hollow tube which extends through the trunk of the body, and its accessory structures: the salivary glands, liver, gallbladder, and pancreas (Fig. 20-1). The digestive tract is divided into two sections, the upper tract, consisting of the mouth, esophagus, and stomach, and the lower tract, consisting of the intestines.

FIGURE 20-1 events.

Anatomy of the digestive system with associated

Inside this tube, ingested food and fluid, along with secretions from various glands, are efficiently processed. First, they are broken down into their separate constituents; then the desired nutrients, water, and electrolytes are absorbed into the blood for use by the cells, and waste elements are eliminated from the body. Within this system, the liver can reassemble the component nutrients into new materials as they are needed by the body. For example, the proteins in milk are digested by enzymes in the digestive tract, producing the component amino acids, which are then absorbed into the blood. The individual amino acids are used by the liver cells to produce new proteins, such as albumin or prothrombin, or they may circulate as they are in the amino acid pool in the blood to be taken up by individual cells as necessary. The peritoneal cavity refers to the potential space between the parietal and visceral peritoneum. A small amount of serous fluid is present in the cavity to facilitate the necessary movement of structures such as the stomach. Numerous lymphatic channels drain excessive fluid from the cavity. Because serous membranes are normally thin, somewhat permeable, and highly vascular, the peritoneal membranes are useful as an exchange site for blood during peritoneal dialysis in patients with kidney failure (see Chapter 21). However, such an extensive membrane may also facilitate the spread of infection or malignant tumor cells throughout the abdominal cavity or into the general circulation. The mesentery is a double layer of peritoneum that supports the intestines and conveys blood vessels and nerves to supply the wall of the intestine. The mesentery attaches the jejunum and ileum to the posterior (dorsal) abdominal wall. This arrangement provides a balance between the need for support of the intestines and the need for considerable flexibility to accommodate peristalsis and varying amounts of content. The greater omentum is a layer of fatty peritoneum that hangs from the stomach like an apron over the anterior surface of the transverse colon and the small intestine. The lesser omen-tum is part of the peritoneum that suspends the stomach and duodenum from the liver. When inflammation develops in the intestinal wall, the greater omentum, with its many lymph nodes, tends to adhere to the site, walling off the inflammation and temporarily localizing the source of the problem. Inflammation of the omentum and peritoneum may lead to scar tissue and the formation of adhesions between structures in the abdominal cavity, such as loops of intestine, restricting motility and perhaps leading to obstruction.

Intestinal Obstruction
Intestinal obstruction refers to a lack of movement of the intestinal contents through the intestine. Because of its smaller lumen, obstructions are more common and occur more rapidly in the small intestine, but they can occur in the large intestine as well. Depending on the cause and location, obstruction may manifest as an acute problem or a gradually developing situation. For example, twisting of the intestine could cause sudden total obstruction, whereas a tumor leads to progressive obstruction. FIGURE 20-37 Colostomy. A, sigmoid colostomy-a surgically created opening into the colon through the abdominal wall. B, The stoma is the new opening on the abdomen. It is always red and moist, is not painful, but may bleed easily. C, A plastic pouch to collect stools is attached to the stoma. (Courtesy of Hollister Incorporated, Patient Education Series.)

Intestinal obstruction occurs in two forms. Mechanical obstructions are those resulting from tumor, adhesions, hernias, or other tangible obstructions (Fig. 20-38). Functional, or adynamic, obstructions result from neurologic impairment, such as spinal cord injury or lack of propulsion in the intestine, and are often referred to as paralytic ileus. While the end result can be the same, these types manifest somewhat differently and require different treatment.

IV. THE PATIENT AND HIS ILLNESS A. Pathophysiology

Schematic Diagram
Risk Factors for Ascariasis: Children less than 10 years old (more likely to play in dirt) Warm climate (eg. Tropical areas) Poor sanitation (human feces mixed in soil) Risk Factors for Bowel Obstruction Abdominal or pelvic surgery which often cause adhesions Crohns disease narrows intestinal passageways due to thickening Abdominal Cancer Ad

2 types of obstructions Ingestion of ascariasis eggs: Contaminated soil Hand-to-mouth contact Eating uncooked fruits or vegetables grown in contaminated soil

Mechanical: Physical obstruction or increased pressure from walls creating a blockage

Functional: Intestinal muscles cannot propel the contents along the bowel

Migration Larvae hatch in small intesting Penetrate intestinal wall and travel through to lungs through blood and lymph vessels After 1 week of maturation, travel into throat and back to intestines

Increased fluid and gas

Increased pressure on intestinal wall causes more fluid to enter intesting

Abdominal distention Decreased blood pressure & hypovolemic shock

Maturation Grow into male and female worms. Females > 40cm long and < 6mm in diameter Males generally smaller

Increased peristalsis attempts to force contents past obstruction

Severe vomiting & pain Reproduction Females produce 200,000 eggs a day Eggs expelled in feces

Continued pressure on intestinal wall causes edema, ischemia and decreased peristalsis

Dehydration & Electrolyte Imbalance

Prolonged ischemia causes increased permeability and necrosis of wall. Intestinal bacteria & toxins leak into blood.

When mechanical obstruction of the flow of intestinal contents occurs, a sequence of events develops (Fig. 20-39) as follows: 1. Gases and fluids accumulate in the area proximal to the blockage, distending the intestine. Gases arise primarily from swallowed air but also from bacterial activity in the intestine; 2. Increasingly strong contractions of the proximal intestine occur in an effort to move the contents onward; 3. The increasing pressure in the lumen leads to more secretions entering the intestine and also compresses the veins in the wall, preventing absorption, as the intestinal wall becomes edematous; 4. The intestinal distention leads to persistent vomiting with additional loss of fluid and electrolytes. With small intestinal obstructions, there is no opportunity to reabsorb fluid and electrolytes, and hypovolemia quickly results; 5. If the obstruction is not removed, the intestinal wall becomes ischemic and necrotic as the arterial blood supply to the tissue is reduced by pressure. If twisting of the intestine (e.g., volvulus) has occurred or if immediate compression of arteries (e.g., intussusception or strangulated hernia) results from the primary cause of obstruction, the intestinal wall becomes rapidly necrotic and gangrenous; 6. Ischemia and necrosis of the intestinal wall eventually lead to decreased innervation and cessation of peristalsis. A decrease in bowel sounds indicates this change; 7. The obstruction promotes rapid reproduction of intestinal bacteria, some of which produce endotoxins. As the affected intestinal wall becomes necrotic and more permeable, intestinal bacteria or toxins can leak into the peritoneal cavity (peritonitis) or into the blood supply (bacteremia and septicemia); and 8. In time, perforation of the necrotic segment may occur, leading to generalized peritonitis.

FIGURE 20-38 AE, Causes of intestinal obstruction.

FIGURE 20-39 Effects of intestinal obstruction.

Functional obstruction or paralytic ileus usually results from neurologic impairment. Peristalsis ceases and distention of the intestine occurs as fluids and electrolytes accumulate in the intestine. In this type of obstruction, reflex spasms of the intestinal muscle do not occur, but the remainder of the process is similar to that of mechanical obstruction.

Etiology
Functional obstruction or paralytic ileus is com-mon in the following situations: after abdominal surgery, in which the effects of the anesthetic combined with inflammation or ischemia in the operative area interfere with conduction of nerve impulses; in the initial stage of spinal cord injuries (spinal shock); with inflammation related to severe ischemia; in pancreatitis, peritonitis, or infection in the abdominal cavity; or with hypokalemia, mesenteric thrombosis, or toxemia

Mechanical obstruction may result from the following: adhesions (from previous surgery, infection, or radiation) that twist or constrict the intestine, the most common cause of obstruction; hernias (protrusion of a section of intestine through an opening in the muscle wall) (Fig. 20-40); strictures caused by scar tissue; masses, such as tumors or foreign bodies;

intussusception (the telescoping of a section of bowel inside an adjacent section). Intussusception may occur secondary to polyps or tumors that pull a section of bowel forward with them (see Fig. 20-40 B); volvulus (twisting of a section of intestine on itself), which may be linked to adhesions. In many cases, the cause of intussusception or volvulus is unknown; Hirschsprung's disease, or congenital megacolon, a condition in which parasympathetic innervation is missing from a section of the colon, impairing motility and leading to constipation and eventually obstruction. Hirschsprung's disease often occurs in conjunction with other anomalies; and gradual obstruction from chronic inflammatory conditions, such as Crohn's disease or diverticulitis

Signs and symptoms

With mechanical obstruction of the small intestine, severe colicky abdominal pain develops as peristalsis increases initially. Borborygmi (audible rumbling sounds caused by movement of gas in the intestine) and intestinal rushes can be heard as the intestinal muscle forcefully contracts in an attempt to propel the contents forward. The signs of paralytic ileus differ significantly in that bowel sounds decrease or are absent, and pain is steady. FIGURE 20-40 A, Hernia with infarcted intestine. The sac consists of the abdominal wall covered by skin (a) at a site weakened by scar tissue, forming a protrusion into which a loop of intestine is compressed (b). This protrusion obstructs the blood flow to the intestinal wall (c) (black infarcted area) as well as the flow of feces inside the intestine. (Courtesy of R. W. Shaw, MD, North York General Hospital, Toronto, Ontario, Canada.) B, Intussusception due to an adenocarcinoma (light colored circular mass) causing acute intestinal obstruction. (B, From Cooke RA, Stewart B: Colour Atlas of Anatomical Pathology, 3rd ed. Sydney, Churchill Livingstone, 2004).

Vomiting and abdominal distention occur quickly with obstruction of the small intestine. Vomiting is recurrent and consists first of gastric contents and then bile-stained duodenal contents. No stool or gas is passed. Restlessness and diaphoresis with tachycardia are present initially. As hypovolemia and electrolyte imbalances progress, signs of dehy-dration, weakness, confusion, and shock are apparent.

Obstruction of the large intestine develops slowly and signs are mild. Constipation and mild lower abdominal pain are common, followed by abdominal distention, anorexia, and eventually vomiting and more severe pain.

Treatment
The underlying cause is treated, and fluids and electrolytes are replaced. Surgery and antimicrobial therapy are required as soon as possible for any strangulation; paralytic ileus may require decompression by suction. (Gould, Barbara E.. Pathophysiology for the Health Professions, 3rd Edition. W.B. Saunders Company, 032006. 20.9.6). <vbk:1-4160-0210-3#outline(20.9.6)>

Background Intestinal nematode infections affect one fourth to one third of the world's population. Of these, the intestinal roundworm Ascaris lumbricoides is the most common. While the vast majority of these cases are asymptomatic, infected persons may present with pulmonary or potentially severe gastrointestinal complaints. Ascariasis predominates in areas of poor sanitation and is associated with malnutrition, iron-deficiency anemia, and impairments of growth and cognition. Ascaris lumbricoides is shown in the image below.

Adult Ascaris lumbricoides.

Pathophysiology A lumbricoides is the largest of the intestinal nematodes affecting humans, measuring 15-35 cm in length in adulthood. Infection begins with the ingestion of embryonated (infective) eggs in feces-contaminated soil or foodstuffs. Once ingested, eggs hatch, usually in the small intestine, releasing small larvae that penetrate the intestinal wall. Larvae migrate to the pulmonary vascular beds and then to the alveoli via the portal veins usually 1-2 weeks after infection, during which time they may cause pulmonary symptoms (eg, cough, wheezing). During the time frame of pulmonary symptoms, eggs are not being shed, and thus diagnosis via stool ovas and parasites is not possible. Eggs are not shed in stool until roughly 40 days after the development of pulmonary symptoms. After migrating up the respiratory tract and being swallowed, they mature, copulate, and lay eggs in the intestines. Adult worms may live in the gut for 6-24 months, where they can cause partial or complete bowel obstruction in large numbers, or they can migrate into the appendix, hepatobiliary system, or pancreatic ducts and rarely other organs such as kidneys or brain. From egg ingestion to new egg passage takes approximately 9 weeks, with an additional 3 weeks needed for egg molting before they are capable of infecting a new host.

V. THE PATIENT AND HIS CARE A. Medical Management a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc.

Medical Management Treatment

Date Ordered Date(s) Performed Date changed / D/C

General Description

Indication(s) or Purpose(s)

Clients Respone to the treatment

D5 .03 NaCl x 5960 gtts/min.

DO: June 21, 2012 DG: June 21, 2012

D5 .03 NaCl x 44 gtts/min.

DG: June 25, 2012 DG: June 26, 2012

A hypotonic solution that has greater concentration of free water molecules that are found inside the cell rather than on its surrounding. Hypo-osmolality possible with infusion because solutions have a lower concentration of electrolytes than plasma does. Transcend all membranes from vascular space to tissue.

Purpose of hypotonic solution is to give up their water to a dehydrated cell so it can return to isotonic equilibrium. Sodium and chloride depletion.

The patient good hydration status was maintained. Sign and symptoms of decreased fluid volumes were reduced and intravenous medication were given.

Medical Management Treatment

Date Ordered Date(s) Performed Date changed / D/C

General Description

Indication(s) or Purpose(s)

Clients Respone to the treatment

D5 IMB 500cc x 8

DO: June 22, 2012 DG: June 22, 2012

D5 IMB 500 cc x11

DG: June 23, 2012 DG: June 24, 2012 DG: June 25, 2012 DG: June 26, 2012 DG: June 27, 2012

It is a sterile, non pyrogenic solution Each 100 ml contains, hydrous 5g: Na lactate, anhydrous 260 mg: KCl 141 mg: magnesium Cl. Hyxahydrate 30 mg: monobasic potassium phosphate, anhydrous 15 mg : and monobasic sodium.

It is indicated to replace and balance fluids and electrolytes because the patient experienced deficiencies such as blood loss.

The patient willingly accepted treatment and is kept hydrated as evidenced by continuous infusion, improvement in her condition and good skin turgor. There were no negative effects noted.

Nursing Responsibilities Before: Before preparing the infusion, the nurse first verifies the primary care providers order indicating the type of solution, the amount to be administered, the rate of flow of the infusion, and any client allergies (e.g., to tape or povidone iodine). Prepare necessary equipments. Prior to initiating the IV infusion, consider how long the client is likely to have the IV, what kinds of fluids to be infused, and what kinds of medications the client will be receiving or is likely to receive. These factors may affect the choice of vein and catheter size. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain the procedure to the client. A venipuncture can cause a discomfort for a few seconds, but there should be no discomfort while the solution is flowing. Use a doll to demonstrate for children, and explain the

procedure to parents. Clients often want to know how long the process will last. The primary care providers order may specify the length of time of the infusion. Unless initiating IV therapy is urgent, provide any scheduled care before establishing the infusion to minimize movement of the affected limb during the procedure. Moving the limb after the procedure has been established could dislodge the catheter. Make sure the clients clothing or gown can be removed over the IV apparatus if necessary. During: Open and prepare the infusion set using sterile technique. Clean the area of the infusion site using topical antiseptic swab then using antiseptic technique insert the catheter and initiate the infusion, use dressing appropriately. Ensure appropriate infusion flow. Hang the solution container on the pole suspended about 1m (3 ft) above the clients head. Apply IV information label to the solution container. After: Document the relevant data, including assessment. Position the client appropriately. Check routinely the IVF site for any problems and IVF tubing for any infiltrations.

b. Drugs Name of drugs -Generic name -Brand name Date Ordered Date taken or given Date changed / D/C DO: June 21, 2012 DG: June 21-25, 2012 Route of Admin. Dosage and frequency General Action Functional classn Mechanism of action Clients response to the medication with actual side effects

Generic Name: Ampicillin Ampicillin Sodium Brand Name: Novo-Ampicillin (CAN), Principen

320mg SIVP q 6

Antibiotic Penicillin Belonging to the penicillin group of beta-lactam antibiotics. It differs from penicillin only by the presence of an amino group. That amino group helps the drug penetrate the outer membrane of gram-negative bacteria. Bactericidal action against sensitive organism; inhibits synthesis of bacterial cell wall, causing cell death.

The patient was prevented for some bacterial invasion and there was no sign of infection.

Generic Name: Diphenhydramine Hydrochloride Brand Name: Benadryl

DO: June 21, 2012 DG: June 21, 2012

14mg SIVP PRN

Antihistamine Anti-motion sickness drug Antiparkinsonian Sedative-hypnotic Diphenhydramine is a first generation antihistamine used to treat a number of conditions

The patient willingly accepted treatment and did not manifest certain allergic reactions.

including: allergic symptoms and itchiness, the common cold, insomnia, motion sickness, and extrapyramidal symptoms. Diphenhydramine also has antiemetic properties which make it useful in treating the nausea that occurs in motion sickness. As it causes marked sedation in many individuals, the less sedating drug dimenhydrinate may be preferred for this purpose.

Generic Name: Ranitidine Hydrochloride Brand Name: ApoRanitidine, Zantac

DO: June 21, 2012 DG: June 21-26, 2012

14 mg SIV q 8

Histamine-2(H2) antagonist Inhibits basal gastric acid secretion and gastric secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin and pentagastrin. Reduces gastric acid secretion and increases gastric mucus and bicarbonate production,

The patient willingly accepted treatment and did not manifest certain allergic reactions.

creating a protective coating on gastric mucosa.

Generic Name: Acetaminophen Brand Name: Paracetamol, Tempra, Tylenol

DO: June 21, 2012 DG: June 22 and 24, 2012

145 mg IV q 4 x T 37.8

Analgesic Antipyretic

Paracetamol is a widely used overthe-counter analgesic (pain reliever) and antipyretic (fever reducer). It is commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remedies. In combination with non-steroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics, paracetamol is used also in the management of more severe pain (such as cancer or postoperative pain).

The patient experienced relief of pain as an action of the medication. He was more relaxed and there were less complains of pain, facial grimaces and guarding behavior.

Nursing Responsibilities Before Observe 10 Rs of administration of drugs Check doctors order three times and verify the patient Check the label of the drug, its name and its expiration date Wash hands before handling the medication

 Assess patients vital signs prior to administering the medication During Administer as indicated (right drug, right dosage, right frequency) Clean the IV insertion for medication with a cotton ball with alcohol. Gradually inject the drug into the port. Slow IV push to prevent infiltration and phlebitis. Administer cautiously and slowly with aseptic technique.

After Observe for the sensitivity and side effects to the drug Reassess patients level of pain at least 15 and 30 minutes after parenteral administration Monitor circulatory and respiratory status and bladder and bowel function. Caution ambulatory patient about getting out of bed or walking.

c. Diet Type of Diet Date General Description Indication Specific foods taken Clients response and/or reaction to the diet NPO (Nothing per Orem) DO: June 21, 2012 A diet wherein the patient will not take in food or liquids by mouth. It was ordered to prepare the patient for further observation and to avoid complication Clear Liquid June 26, 2012 A clear or full liquid diet, or a
Was ordered to

None

The

patient

seems to be irritated most probably due to hunger. . Fruit juices no carbonated drinks The patient complied with

of aspiration.

diet containing no solid foods, is often prescribed for gastrointestinal illness or before or after certain types of surgery involving the mouth or gastrointestinal tract.

prepare the patient for certain medical tests, more commonly bloodwork. It is very helpful when a patient is expereince nausea and has trouble keeping things down. Also used before surgery.

the type of diet without any complain.

A clear liquid diet and after consists of transparent liquid foods, and no carbonated drinks. Soda's carbonation expands the gastrointestinal tract. Nursing Responsibilities (NPO): Before: Check for the doctors order for type of diet preferred. Explain the importance and purpose of the prescribed diet. Place an NPO sign on the bed. Remove all foods at bedside and emphasize strict compliance on the diet regimen. During: Monitor patient closely for compliance of the diet. Reiterate diet frequently to the patient or SO. Check bedside for presence of food, remove if necessary.

After: Assess patients condition. Document

Nursing Responsibilities (DAT): Before: Check the doctors order. Instruct the client about the prescribed diet ordered by the physician. Explain purpose or importance of the diet and what specific foods are allowed for the patient. Explain also the appropriate foods not to be taken such as during NPO: not to eat anything; and during liquid and soft diet: not to eat fibrous or hard to digest food such as vegetables and the like.

During: Assist the patient when eating. As much as possible, promote independence. If appropriate and tolerated, allow the patient to sit in a semi-fowlers or high fowlers position to reduce the risk for aspiration. After: Monitor the reaction of the patient such as dysphagia, anorexia, and intolerance of food. Note patient about the prescribed drugs taken orally but still under NPO.

D. Activity/Exercise

Type of Exercise

Date ordered Date Performed Date changed

General Description

Indication, Initial Reaction, Purpose Ambulation is an essential activity that prevents respiratory, circulatory, and gastrointestinal problems. It also helps the patient to prevent general muscle weakness.

Client response to activity exercise The patient gradually increased activity performance as evidenced by the patient tolerated activity such as sitting, standing and walking.

Ambulation

May sit on side of bed and walk around the room

Nursing Responsibilities: Prior to: Check for the doctors order Assess patients condition Assess for Vital signs. Explain the benefit that the patient may get from this activity. During: Assist patient in the activity After: Advise the patient to have rest periods to avoid fatigue. Instruct the patient to gradually increase activities as tolerated.

Monitor patients vital signs. Advise patient to report to the physician any unusual fatigability to the physician because this may indicate activity intolerance. Monitor for vital signs to assess for tolerance to activity. Provide health teaching regarding the proper food to be taken to provide adequate supply of energy.